Factors influencing plasma transfusion practices in paediatric intensive care units around the world.

BACKGROUND AND OBJECTIVES: Plasma transfusions are a frequent treatment worldwide, but many studies have reported a wide variation in the indications to transfuse. Recently, an international paediatric study also showed wide variation in frequency in the use of plasma transfusions: 25% of the centres transfused plasma to >5% of their patients, whereas another 25% transfused plasma to <1% of their patients. The objective of this study was to explore the factors associated with different plasma transfusion practices in these centres. MATERIALS AND METHODS: Online survey sent to the local investigators of the 101 participating centres, in February 2016. Four areas were explored: beliefs regarding plasma transfusion, patients' case-mix in each unit, unit's characteristics, and local blood product transfusion policies and processes. RESULTS: The response rate was 82% (83/101). 43% of the respondents believed that plasma transfusions can arrest bleeding, whereas 27% believe that plasma transfusion can prevent bleeding. Centres with the highest plasma transfusion rate were more likely to think that hypovolaemia and mildly abnormal coagulation tests are appropriate indications for plasma transfusions (P = 0·02 and P = 0·04, respectively). Case-mix, centre characteristics or local transfusion services were not identified as significant relevant factors. CONCLUSION: Factors influencing plasma transfusion practices reflect beliefs about indications and the efficacy of transfusion in the prevention and management of bleeding as well as effects on coagulation tests. Educational and other initiatives to target these beliefs should be the focus of research.

First-line treatment using high-flow nasal cannula for children with severe bronchiolitis: Applicability and risk factors for failure.

BACKGROUND: Viral bronchiolitis is the leading cause of hospitalization in children during the first 12 months of life. There is evidence to support the use of noninvasive ventilation in bronchiolitis. A recent respiratory management of bronchiolitis is the use of high-flow nasal cannula (HFNC) therapy. The primary objective of this study was to evaluate the use of HFNC as the first-line treatment for children with severe bronchiolitis and the secondary objective was to identify factors for HFNC therapy failure. METHODS: Observational prospective study in a pediatric intensive care unit (PICU), during two consecutive seasons (2013-2014 without recommendation and 2014-2015 with a study design suggesting HFNC as first-line treatment). The percentages of children treated with HFNC, nasal continuous or biphasic positive airway pressure (nCPAP/BiPAP) and invasive ventilation were compared. Associations between parameters recorded and HFCN therapy failure were established. RESULTS: The percentage of patients treated with HFNC at admission was higher during the second season (90%, n=55/61) than the first season (34%, n=14/41) (p<0.0001). In bivariate analysis, heart rate, pH, and pCO2 were significantly associated with the occurrence of HFNC therapy failure in time-varying Cox regression models using all available values (i.e., admission and repeated measures during the first 5 days of hospitalization). Only pCO2 remained independently associated as a factor of HFNC failure in the multivariate Cox model with a hazard ratio per 5mmHg of 1.37 (95%CI: 1.01-1.87; P=0.046). CONCLUSION: In our PICU, HFNC therapy for children with bronchiolitis can potentially decrease the use of nCPAP. In this study, the factor of failure was higher pCO2. Studies to evaluate PCO2 level to discriminate HFNC versus CPAP indication could be useful.

[Evaluation of the antibiotic prescription in a paediatric intensive care unit]. / Evaluation de la prescription antibiotique dans un service de réanimation pédiatrique.

UNLABELLED: The antibiotic prescription in intensive care units is frequent using often broad-spectrum antibiotics; its quality has never been evaluated in paediatric intensive care units. OBJECTIVES: To describe the modalities of antibiotic prescriptions in a paediatric intensive care unit and confront them to the literature guidelines and bacteriological data. METHODS: From January 1st to March 31st 2005, 52 consecutive prescriptions regarding 45 children, with a total of 47 hospitalisations were prospectively analysed. RESULTS: Confirmed diagnosis of bacterial infection was retained for 50 of the 52 patients: community acquired infection in 35 cases (70%) and a nosocomial infection in 15 cases. Ten children died during the antibiotic treatment (22%), with 5 deaths related to the infection (11%). Monotherapy represented 56% of the prescriptions of antibiotics. The initial antibiotic treatment was empirical in 42 of 52 cases (81%). The empirical prescriptions were documented afterward in 48% of cases. One or more microorganisms were isolated for 60% of the initial prescriptions. Misuses in antibiotic doses (in excess [10%] or by insufficiency [13%]), number of daily administration (4%), and way of administration and/or length of treatment were observed. Seventy-seven percent of the initial prescriptions seemed to be adapted to the identified or suspected bacteria, but only 63% adequate to recommendations. CONCLUSION: Almost 2/3rd of the antibiotic prescriptions were adequate to the recommendations. The implementation of standardized and specific protocols should contribute to improve the quality of these prescriptions.

[Non-invasive ventilation in infants with severe infection presumably due to respiratory syncytial virus: feasibility and failure criteria]. / Ventilation non invasive des nourrissons ayant une infection respiratoire sévère présumée à virus respiratoire syncitial: faisabilité et critères d'échec.

UNLABELLED: Beneficial effect of continuous positive airway pressure (CPAP) during non invasive ventilation (NIV) has been reported in infants with respiratory syncytial virus (RSV) infection, but no study has analyzed the predictors of its failure. OBJECTIVE: To evaluate the feasibility of NIV and to determine NIV failure criteria. POPULATION AND METHODS: All infants hospitalized in one PICU with presumed RSV infection between 2002 and 2006 were prospectively included. When respiratory support was needed, NIV was first started according to a pre-established protocol. RESULTS: One hundred and one infants, 43 females, 58 males, median age 49 days (range: 10-334), median weight 3.9 kg (range: 2,4-12) were included. RSV infection was confirmed in 84/101. Sixty-seven infants were transported by the paediatric medical transport system, 27 with NIV and 15 with invasive ventilation (IV). Fifteen infants were in IV at admission, 69 received NIV during their PICU stay (12 secondarily requiring IV) and 17 were never ventilated. A significant decrease in PCO2 with increase in pH was observed within 2 hours of NIV. Parameters associated with NIV failure were apneas, high values of admission PCO2 and H24 PRISM score. The 17 non-ventilated infants were older and had a lower severity score than those who were ventilated. CONCLUSION: In infants with RSV and needing respiratory support, NIV represented the sole method of respiratory support in 68% of cases. NIV failure criteria were apneas, high values of admission PCO2 and H24 PRISM score.

Plastic bronchitis mimicking foreign body aspiration that needs a specific diagnostic procedure.

OBJECTIVE: To report two children admitted to our emergency department with respiratory failure, one for status asthmaticus with pneumomediastinum and requiring mechanical ventilation and the other for high suspicion of foreign body aspiration. INTERVENTIONS: Bronchoscopy revealed obstructive plugs and permitted their extraction and their identification as bronchial casts after the immersion in normal saline. Allergy was suspected in the first one, and Hemophilus influenzae infection was present in the second. The outcome was favorable. CONCLUSIONS: Plastic bronchitis is an infrequent cause of acute life-threatening respiratory failure that can mimic foreign body aspiration or status asthmaticus. Bronchoscopic extraction must be performed urgently in the case of severe obstruction. This entity is probably underestimated as the casts with their specific ramifications are difficult to recognize. We recommend the immersion in normal saline of all plugs discovered in children with predisposing diseases mainly represented by infections, allergy, acute chest syndrome, and congenital cardiopathies.

Reproducibility of the respiratory dead space measurements in mechanically ventilated children using the CO2SMO monitor.

OBJECTIVES: To assess the reproducibility of respiratory dead space measurements in ventilated children. DESIGN: Prospective study. SETTING: University pediatric intensive care unit. PATIENTS: Thirty-two mechanically ventilated children (0.13-15.4 years) who were clinically stable. METHODS: The single-breath CO(2) test (SBT-CO(2)) was recorded using the CO(2)SMO Plus from the mean of 30 ventilatory cycles during 1 h (at T0, T15, T30, T45, and T60). Airway dead space was determined automatically (Novametrix Medical Systems, USA), and manually by Bohr- Enghoff equations using data obtained by SBT-CO(2). At the end of the study period, arterial blood gas was sampled in order to calculate alveolar and physiologic dead space. Intrasubject reproducibility of measurements was evaluated by the intraclass correlation coefficient. Two-way analysis of variance was used to evaluate the relationships between time and measurements. The two methods for calculating airway dead space were compared by using two-tailed Student's t-test and Bland-Altman analysis. RESULTS: Airway dead space measurement had a good reproducibility during the 1-h period, whatever the method used (intraclass correlation coefficient: 0.84 to 0.87). No significant difference was observed with time. Airway dead space values from the SBT-CO(2) method were smaller than those from Bohr-Enghoff equations. Physiologic dead space values from the SBT-CO2 method were similar to those from Bohr-Enghoff equations. CONCLUSION: The measurement of airway dead space by the CO(2)SMO Plus was reproducible over a 1-h period in children requiring mechanical ventilation, provided ventilatory parameters were constant throughout the study. SBT-CO(2) analysis may provide a bedside non-invasive monitoring of volumetric capnography.

Admission plasma vasopressin levels in children with meningococcal septic shock.

OBJECTIVE: Vasopressin (AVP) response has been reported to be inappropriately low in adult established septic shock. We studied admission AVP levels in children with meningococcal septic shock (MSS). PATIENTS AND METHODS: All children with meningococcal infection admitted to our PICU between May 2001 and August 2002 were classified as MSS (persistent hypotension despite fluid therapy, with perfusion abnormalities and the need for vasoactive drug infusion for at least 24 h or until death), or meningococal infection without shock (fever and purpura, with or without meningitis). Blood samples were collected at admission and AVP levels were subsequently determined using Nichols Institute Diagnostics vasopressin assay. Eighteen of 19 children with MSS (7 deaths) and 15 without shock (no death) were included. RESULTS: In children with MSS median admission AVP level was 41.6 pg/ml (1.4-498.9) and in those without 3.3 pg/ml (1.6-63.8). In children with MSS the AVP level was not correlated with duration of shock and fluid expansion prior to AVP sampling, or with age-adjusted blood pressure and natremia at the time of blood sampling. AVP levels were higher in nonsurvivors, but not significantly so. Only one nonsurvivor had an admission AVP level below 30 pg/ml. CONCLUSIONS: In our children with established MSS who died the admission AVP level Delta were not inappropriately low. Further studies including serial AVP level assessments are needed before concluding that AVP administration is of little interest in children with MSS.

Development of a pediatric multiple organ dysfunction score: use of two strategies.

BACKGROUND: An organ dysfunction (OD) scoring system for critically ill children is not yet available, and the method for developing such a system is not well defined. The aim of this study was to compare two developmental methods for assessing OD in critically ill children. METHODS: Consecutive admissions between January and May 1997 in three French and Canadian pediatric intensive care units (PICUs) were studied prospectively. Physiologic data were selected using a Delphi method; the most abnormal values during PICU stay were recorded. The outcome measure was the vital status at PICU discharge. Six organ systems were studied: hepatic, cardiovascular, renal, hematologic, respiratory, and neurologic. For each of the six organ systems, the PEdiatric Multiple OD (PEMOD) system included one variable and the PEdiatric Logistic OD (PELOD) system included several variables. Severity levels and relative weights of ODs were determined according to the mortality rate (PEMOD) or by logistic regression (PELOD). RESULTS: There were 594 admissions, including 51 deaths (9%). Severity levels and relative weights of ODs were: four levels graded from 1 to 4 for the PEMOD system and three levels with scores of 1, 10, and 20 for PELOD system. For both systems, calibrations were good (p = 0.23 and p = 0.44 respectively). The PELOD system was more discriminant than the PEMOD system (areas under the ROC curves 0.98 and 0.92, respectively, p < 10(-5)). Moreover, with the PEMOD system, four ODs did not contribute significantly to the prediction of PICU outcome. CONCLUSIONS: The PELOD system was more discriminant and had the advantage of taking into account both the relative severities among ODs and the degree of severity of each OD.

[Characteristics of patients and use of resource in French pediatric intensive care units. Le groupe francophone de Rèanimation et urgences pédiatriques]. / Caractéristiques des patients et utilisation des ressources dans les services de réanimation pédiatrique français. Le groupe francophone de Réanimation et urgences pédiatriques.

UNLABELLED: Evaluation of case-mix and resource consumption in pediatric intensive care units (ICU) is required. AIMS: This study describes the patterns of pediatric ICU resource consumption, determines the impact of primary clinical characteristics (particularly severity of illness) on resource utilization, and analyses medical efficiency with the frequency of inappropriate stays in French pediatric ICU. METHODS: Prospective study in nine French volunteer multidisciplinary pediatric ICUs from December 1993 to April 1994. Premature neonates were excluded. Resource consumption was expressed using the Omega system and length of stay, from which total Omega per admission, and average daily Omega (total Omega/length of stay) were obtained. RESULTS: Seven hundred and twelve patients were eligible. Twenty-five percent were full-term neonates, 30% infants (1 month to 1 year), and 45% children. Surgical patients constituted 22% of the population. A chronic disease was present in 45% of infants and children. Immunodeficiency was present in 10% of patients. The median length of stay was 4 days (range: 1-155). The mean Omega scores per admission were: total Omega = 92 +/- 124, Omega/day = 14 +/- 9. Sixty-four percent required mechanical ventilation and 37% during more than 2 days. Forty-two percent had a central venous access, and 23% an arterial line. The resource consumption was greater in non-survivors, surgical patients, neonates, and immunosuppressed patients. The mean PRISM score was 9 +/- 9. Mortality was 13%. The Omega/day and the PRISM score correlated. The frequency of inappropriate stays was 7.6% and accounted for 1.0% of the overall Omega activity. CONCLUSIONS: The results of this study can be used for interinstitutional comparison and a broader appraisal of pediatric intensive care. They illustrate the relationship between severity of illness and resource consumption. French pediatric ICU efficiency seems to be high, as compared to North American and Dutch results.

[Upper airway obstruction (foreign bodies excluded)]. / Obstruction des voies aériennes supérieures (à l'exclusion des corps étrangers).

Upper airway obstruction is a frequent cause of admission to the emergency department and the intensive care unit. Symptoms are mainly represented by dyspnea and stridor. Severity must be rapidly assessed to allow adapted treatment and avoid cardiac arrest and hypoxic encephalopathy. The possible etiologies are numerous, with acquired and congenital ones, but the majority is represented by laryngitis, lymphoid hypertrophy and laryngotracheomalacia. In case of respiratory failure, treatment must first establish airway patency with bag and mask ventilation, and then intubation. If vital prognosis is not threatened, biologic, radiologic or endoscopic examination can be performed to identify the cause of the obstruction and treat it.

[Impact of vaccination against Haemophilus influenzae on the incidence of invasive infections from Haemophilus influenzae type B in the Nord-Pas-de-Calais region]. / Impact de la vaccination anti-Haemophilus influenzae sur l'incidence des infections invasives à Haemophilus influenzae de type b dans la région Nord-Pas-de-Calais.

BACKGROUND: In industrialized countries where immunization against Haemophilus influenzae b (Hib) is largely used, the incidence of invasive Hib infections has dramatically decreased. The aim of this study was to analyse the impact of immunization against Hib on the incidence of invasive Hib infections in the Nord-Pas-de-Calais area in France. PATIENTS AND METHODS: This retrospective multicenter study enrolled 11 of the 18 hospitals in the Nord-Pas-de-Calais area, comparing two periods: 1991-1993 (before immunization), and 1994-1996 (during immunization). All children less than 60 months of age and having an invasive Hib infection were included. The Pasteur-Mérieux Company was asked to provide the number of vaccines sold in the Nord-Pas-de-Calais area during the study period. RESULTS: The number of vaccines sold in 1992 was 56,208; this reached 189,173 in 1996, corresponding to an immunization ratio higher than 90%. One hundred and two children representing 155 invasive Hib infections were studied. The annual incidence was 42 during the first period (meningitis: 18.6; septicemia: 14.6; epiglottitis: 5.6), and nine (meningitis: 5; septicemia: 2.6; epiglottitis: 0.3) during the second period, that is a 78% decrease. CONCLUSION: These results confirm previous data in the literature by demonstrating that immunization in the Nord-Pas-de-Calais area has dramatically decreased the incidence of invasive Hib infections.

[Acute rhabdomyolysis in the child]. / Rhabdomyolyses aiguës de l'enfant.

Rhabdomyolysis results from muscular fibre lysis with release of cellular contents (myoglobin, enzymes, electrolytes) into the plasma. Traumatic (crush syndrome) and non-traumatic rhabdomyolysis have been mostly reported in adults. Traumatic rhabdomyolysis are mostly due to ischemic and reperfusion injuries. Non-traumatic rhabdomyolysis include several factors: muscular compression (comas), cytotoxic injury (infections and poisonings), ischemia (shock, cardiorespiratory arrest) or excessive muscular activity (seizures, strenuous exercise). The main etiologies reported in children are: anoxic-ischemic encephalopathy (including sudden infant death and life threatening events); electrolyte disorders; severe hyperthermia; poisonings; hereditary myopathies. Non-traumatic rhabdomyolysis must be suspected in these circumstances, requiring blood creatinine phosphokinase measurements. Indeed, clinical signs are inconstant and non-specific, and functional signs are difficult to appreciate in children. During the initial phase, the main risk is arrhythmias secondary to hyperkalemia. The two main complications are the compartmental syndrome leading to irreversible vasculo-nervous injuries and acute renal failure. Treatment of traumatic and non-traumatic rhabdomyolysis includes correction of hyperkalemia, active fluid loading in order to prevent acute renal failure and alkalinisation. Prognosis of rhabdomyolysis relates to the aetiology and the presence of acute renal failure.

[Treatment of meningococcal purpura fulminans]. / Traitement du purpura fulminans méningococcique.

In France, the incidence of meningococcal infections is increasing. The most severe presentation, called purpura fulminans, has a death rate of 20-25%; 5 to 20% of the survivors need skin grafts and/or amputations. Diagnosis of invasive meningococcal infection is very difficult when purpura and "toxic" appearance are absent: one should take into account parents' impression of their ill child. This diagnosis must be evoked in any child presenting with febrile purpura (like in the United Kingdom, parents should be encouraged to use the "tumbler test" to identify a vasculitic rash); a fulminant form is to be suspected in the presence of only one ecchymosis and signs of infection, remembering that recognition of shock is difficult in children. Recently, the Health Authority has recommended to administer a third generation cephalosporin promptly (before biological investigations) for any child with signs of infection and a necrotic or ecchymotic purpura (> 3 mm of diameter), and then to refer the patient to the hospital. By grouping the patients from 7 studies, it can be observed that preadmission antibiotic administration has a protective effect on mortality (odds ratio: 0.36; 95% confidence interval: 0.23-0.56); a negative effect was observed in only one of these series. Children with purpura fulminans should be referred to a paediatric intensive care unit. Management includes antibiotics, steroids, fluid resuscitation and catecholamines (be aware of hypoglycaemia, particularly in infants, and hypocalcaemia). Treatment of cutaneous necrosis and distal ischemia is difficult and still controversial: antithrombin, protein C, tissue plasminogen activator and vasodilator infusion have no proven efficacy. Cases must be rapidly notified to the Public Health Service who will institute chemoprophylaxis for close contacts. Given the predominance of serogroup B in France, we hope that an efficient vaccine will soon become available.

[Multi-parameter indices of weaning from mechanical ventilation in children]. / Indices multi-paramétriques pour le sevrage de la ventilation mecanique chez l'enfant.

UNLABELLED: Simple clinical markers have poor sensitivity; specificity and predictive value in both infants and adults when predicting the success of weaning from mechanical ventilation. Recently, multi-parametric indices, such as the CROP (Compliance-Respiratory Rate-Oxygenation-Pressure) and the RSB (Rapid-Shallow-Breathing) have been used in adults and subsequently in children. The aim of this study was to test the value of the pediatric CROP and RSB (CROPp, RSBp) and the accuracy of a simplified pediatric CROP (CROPpS) that does not require an arterial blood gas sample. MATERIALS AND METHODS: This prospective study was conducted in a pediatric ICU which does not admit neonates. All infants were intubated and ventilated at the time of entry. Spontaneous tidal volume and maximal negative inspiratory pressure, that are required to assess and calculate the indices, were measured using a Fleish pneumotachograph and a unidirectional valve. The other parameters were recorded or calculated. A maximum 4 hour-duration trial of spontaneous ventilation was then performed. Weaning failure was defined as the requirement of re-ventilation within 48 hours of extubation. The discriminant power of CROPp and RSBp was determined by calculating the area under the receiver operating characteristic (ROC) curve. The best cut-off value of the CROPpS was determined by chi2 optimisation. RESULTS: 39 children (20 males) were included in the trial. They had a median age of 3.2 years and a median duration of mechanical ventilation of 1.3 days. 89.7% of children were successfully weaned of mechanical ventilation. Sensitivity of CROP, and RSB, was 97% and 94%, specificity was 0% and 0%, positive predictive value was 89% and 89%, and negative predictive value was 0% and 0% respectively; the area under the ROC curve was 0.57 and 0.74. The CROP,S was found to be as accurate as the CROP, index using the same cut-off value. Comparison of the 2 groups (success, failure) revealed a significant difference in duration of ventilation (longer in the failure group). CONCLUSION: Even though they correctly classified 87% and 85% of patients respectively, the CROPp and RSBp are not good predictors of weaning from mechanical ventilation as the area under the ROC curve is less than 0.80. Other indices need to be evaluated.

[Sodium dichloroisocyanurate-induced acute lung injury in a child]. / Œdème pulmonaire lésionnel par intoxication au dichloro-isocyanurate de sodium.

Intoxication, by cyanurate and its chlorated derivatives in children, is increasingly reported in the literature due to accidental ingestion compared to accidental inhalation. We report a case in a 5-year-old child who presented with acute lung injury due to accidental inhalation of gas formed after a reaction of sodium dichloroisocyanurate tablets with water. Prevention remains the best way to reduce the risk of children being intoxicated by inhalation of the gas formed after contact of tablets with water.

[Haemophilia A and intracranial bleedings in infants]. / Hémophilie A et saignements intracrâniens du nourrisson.

BACKGROUND AND PURPOSE: Haemophilia is a well-known X-linked recessive bleeding disorder related to a deficiency of factor VIII. The aim of the paper is to point out the role of an early diagnosis in cases of intracranial bleeding, especially in neonates and to highlight the bad prognosis. METHODS: Three patients were included in the study from our prospective data. All had severe factor VIII deficiency (less than 1%). RESULTS: The first of them was a newborn without familial history of haemophilia which presented with hypotonia and seizures after a delivery with vacuum. CT showed a subdural haematoma and MRI multiple ischemic lesions. Two months later, he died from a new intracranial haemorrhagic episode resistent to infusion of factor VIII related to development of an anti-factor VIII antiboby. The second neonate had no familial history more and experienced hypothermia and areactive mydriasis because of an acute subdural haematoma. He died eight days later of ischemic lesions in spite of a craniotomy. The third was a 5-month-old boy with a familial history. Physical examination revealed lethargy, seizure and a recent cranial perimeter increase. He underwent a craniotomy with a good result. CONCLUSION: The authors stress the need for immediate factor VIII infusion and appropriate neurosurgical work-up. The rapid medical management is mandatory if morbidity and mortality are to be minimized.

Molecular method for the diagnosis of imported pediatric malaria.

Malaria is a polymorphous disease; it can be life threatening especially for children. We report a case of imported malaria in a boy, illustrating the epidemiological and clinical aspects of severe pediatric malaria. In this case real-time PCR was used to quantify Plasmodium falciparum DNA levels, to monitor the evolution under treatment, and to determine genetic mutations involved in chloroquine resistance. The major epidemiological features of imported malaria, and the difficulty to diagnose childhood severe malaria are described. The contribution of molecular methods for the diagnosis of imported malaria is discussed.